Reactive attachment disorder is a rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers. Reactive attachment disorder may develop if the child's basic needs for comfort, affection and nurturing aren't met and loving, caring, stable attachments with others are not established.

With treatment, children with reactive attachment disorder may develop more stable and healthy relationships with caregivers and others. Treatments for reactive attachment disorder include positive child and caregiver interactions, a stable, nurturing environment, psychological counseling, and parent or caregiver education.

Reactive attachment disorder can start in infancy. There's little research on signs and symptoms of reactive attachment disorder beyond early childhood, and it remains uncertain whether it occurs in children older than 5 years.

Signs and symptoms may include:

Withdrawal, fear, sadness or irritability that is not readily explained

Sad and listless appearance

Not seeking comfort or showing no response when comfort is given

Failure to smile

Watching others closely but not engaging in social interaction

Failing to ask for support or assistance

Failure to reach out when picked up

No interest in playing peekaboo or other interactive games

Reactive attachment disorder is rare. Signs and symptoms can occur in children who don't have reactive attachment disorder or who have another disorder such as autism spectrum disorder. It's important to have your child evaluated by a psychiatrist who can tell whether such behaviors indicate a more serious problem.

When to see a doctor

If you think your child may have reactive attachment disorder, you may start by visiting your primary care provider or pediatrician. However, you may be referred to a doctor who specializes in the diagnosis and treatment of reactive attachment disorder or a pediatrician specializing in behavior and development for a complete evaluation.

Consider getting an evaluation if your baby or child shows any of the signs and symptoms above.

To feel safe and develop trust, infants and young children need a stable, caring environment. Their basic emotional and physical needs must be consistently met. For instance, when a baby cries, his or her need for a meal or a diaper change must be met with a shared emotional exchange that may include eye contact, smiling and caressing.

A child whose needs are ignored or met with a lack of emotional response from caregivers does not come to expect care or comfort or form a stable attachment to caregivers.

Most children are naturally resilient, and even those who've been neglected, lived in orphanages or had multiple caregivers can develop healthy relationships. It's not clear why some babies and children develop reactive attachment disorder and others don't.

Various theories about reactive attachment disorder and its causes exist, and more research is needed to develop a better understanding and improve diagnosis and treatment options.

The risk of developing reactive attachment disorder from serious social and emotional neglect or the lack of opportunity to develop stable attachments may increase in children who:

Live in a children's home or other institution

Frequently change foster homes or caregivers

Have inexperienced parents

Have prolonged separation from parents or other caregivers due to hospitalization

Have a mother with postpartum depression

Are part of an unusually large family, such that parental time is scarce or available unequally or rarely

However, most children who are severely neglected don't develop reactive attachment disorder.

Without treatment, reactive attachment disorder can continue for several years and may have lifelong consequences. However, more research is needed to determine if problems in older children and adults are related to experiences of reactive attachment disorder in infancy and early childhood.

It's a good idea to be well-prepared for your appointment. Here's some information to help you get ready and know what to expect from your doctor.

What you can do

Before your appointment make a list of:

Any behavior problems or emotional issues you've noticed, and include any signs or symptoms that may seem unrelated to the reason for your child's appointment

Key personal information, including any major stresses or life changes that you or your child have been through

All medications, vitamins or other supplements your child is taking, including the dosages

Questions to ask your child's doctor

For signs and symptoms that could be caused by attachment problems, some basic questions to ask your doctor include:

What are the alternatives to the primary approach that you're suggesting?

My child has these other mental or physical health conditions. How can I best manage them together?

Are there any restrictions that my child needs to follow?

Should I take my child to see other specialists? Will my insurance cover that?

Is there a generic alternative to the medicine you're prescribing for my child?

Are there any brochures or other printed material that I can have? What websites do you recommend?

What to expect from your doctor

Your child's doctor or mental health provider is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Some questions the doctor may ask include:

When did you first notice problems with your child's behavior or emotional responses?

Have your child's behavioral or emotional issues been continuous or occasional?

How are your child's behavioral or emotional issues interfering with his or her ability to function or interact with others?

Can you describe your child's and the family's home and living situation since birth?

Can you describe interactions with your child?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, includes diagnostic criteria for reactive attachment disorder, such as:

A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed

Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers

Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)

No diagnosis of autism spectrum disorder

However, some experts use other sources, rather than the DSM-5, as a basis for diagnosing reactive attachment disorder.

Psychiatric evaluation

A thorough, in-depth examination by a child psychiatrist is necessary to diagnose reactive attachment disorder.

Your child's evaluation may include:

Direct observation of interaction with parents or caregivers

Details about the pattern of behavior over time

Examples of the behavior in a variety of situations

Information about interactions with parents or caregivers, as well as others

Questions about the home and living situation since birth

An evaluation of parenting and caregiving styles and abilities

Your child's doctor will also want to rule out other possible causes, as signs and symptoms of reactive attachment disorder may resemble those related to other disorders, including:

Intellectual disability

Adjustment disorders

Autism spectrum disorder

Depressive disorders

Children with reactive attachment disorder are believed to have the capacity to form attachments, but this ability has been compromised by their experiences. The best treatment for a child with reactive detachment disorder is a positive, loving, stable, caring environment and caregiver.

There's no standard treatment for reactive attachment disorder, but it should involve both the child and parents or primary caregivers. Early intervention appears to improve outcomes. Goals of treatment are to help ensure that the child:

Has a safe and stable living situation

Develops positive interactions with parents and caregivers

Treatment strategies include:

Encouraging the child's development by being nurturing, responsive and caring

Providing consistent caregivers to encourage a stable attachment for the child

Providing a positive, stimulating and interactive environment for the child

Addressing the child's medical, safety and housing needs, as appropriate

Other services that may benefit the child and the family include:

Individual and family psychological counseling

Education of parents and caregivers about the condition

Parenting skills classes

Controversial and coercive techniques

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association and the American Professional Society on the Abuse of Children have all criticized dangerous and unproven treatment techniques for reactive attachment disorder.

These techniques include any type of therapy that involves forcing or coercing a child in order to break down what is believed to be the child's resistance to attachments — an unproven theory of the cause of reactive attachment disorder. These controversial practices can be psychologically and physically damaging and have led to accidental deaths.

Beware of mental health providers who promote unorthodox or extreme methods. Some offer research as evidence to support their techniques, but none has been published in reputable medical or mental health journals.

If you're considering any kind of unconventional treatment, talk to your child's psychiatrist first to make sure it's legitimate and not harmful.

If you're a parent or caregiver whose child has reactive attachment disorder, it's easy to become angry, frustrated and distressed. You may feel like your child doesn't love you — or that it's hard to like your child sometimes.

You may find it helpful to:

Check with your doctor or social service agencies to see what resources are available in your community.

Find someone who can give you a break from time to time. It can be exhausting caring for a child with reactive attachment disorder. You'll begin to burn out if you don't periodically have downtime — but avoid using multiple caregivers.

Practice stress management skills, such as yoga or meditation, to help you relax and not get overwhelmed.

Make time for yourself. Maintain your hobbies, social engagements and exercise routine.

Acknowledge it's OK to feel frustrated or angry at times, and that the strong feelings you may have about your child are natural.

While it's not known with certainty if reactive attachment disorder can be prevented, there may be ways to reduce the risk of its development.

Educate yourself about attachment issues if your child has a background that includes institutions or foster care. Ask your pediatrician about resources, check reputable Internet sites, or consider checking with an adoption agency to identify educational materials and other resources.

Take classes or volunteer with children if you lack experience or skill with babies or children. This will help you learn how to interact in a nurturing manner.

Be actively engaged with your child by lots of playing, talking to him or her, making eye contact, and smiling.

Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.

Provide warm, nurturing interaction with your child, such as during feeding, bathing or changing diapers.

Offer both verbal and nonverbal responses to the child's feelings through touch, facial expressions and tone of voice.

Boris NW, et al. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry. 2005;44:1206.

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